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Major or Mild Vascular Neurocognitive Disorder
DSM-III In DSM-III, this disorder is called Multi-infarct Dementia Diagnostic Criteria A'''. Dementia. '''B. Stepwise deteriorating course (i.e., not uniformly progressive) with "patchy" distribution of deficits (i.e., affecting some functions, but not others) early in the course. C'''. Focal neurological signs and symptoms (e.g., exaggeration of deep tendon reflexes, extensor plantar response, pseudobulbar palsy, gait abnormalities, weakness of an extremity, etc). '''D. Evidence, from the history, physical examination, or laboratory tests, of significant cerebrovascular disease that is judged to be etiologically related to the disturbance. Subtypes Multi-infarct Dementia * with delirium * with delusions * with depression * uncomplicated Differential Diagnosis Stroke A single stroke may cause a relatively circumscribed change in the mental state, such as an aphasia following damage to the left hemisphere, or an Amnestic Syndrome from infarction in the region of the posterior cerebral arteries. As a general rule, a single stroke does not cause Dementia. Multi-infarct Dementia results from the occurrence of multiple strokes, at different times. Primary Degenerative Dementia In Primary Degenerative Dementia the course in uniformly progressive rather than stepwise as in Multi-infarct Dementia, and there is usually no evidence of cerebrovascular disease. In some instances both Multi-infarct Dementia and Primary Degenerative Dementia may coexist, with clinical features of both entities. In such cases both diagnoses should be recorded. DSM-IV In DSM-IV, this disorder is called Vascular Dementia For more information, see Dementia Diagnostic Criteria A'''. The development of multiple cognitive deficits manifested by both # memory impairment (impaired ability to learn new information or to recall previously learned information) # one (or more) of the following cognitive disturbances: #* '''a. aphasia (language disturbance) #* b'''. apraxia (impaired ability to carry out motor activities despite intact motor function) #* '''c. agnosia (failure to recognize or identify objects despite intact sensory function) #* d'''. disturbance in executive functioning (i.e., planning, organizing, sequencing, abstracting) '''B. The cognitive deficits in Criteria A1 and A2 each cause significant impairment in social or occupational functioning and represent a significant decline from a previous level of functioning. C'''. Focal neurological signs and symptoms (e.g., exaggeration of deep tendon reflexes, extensor plantar response, pseudobulbar palsy, gait abnormalities, weakness of an extremity) or laboratory evidence indicative of cerebrovascular disease (e.g., multiple infarctions involving cortex and underlying white matter) that are judged to be etiologically related to the disturbance. '''D. The deficits do not occur exclusively during the course of a delirium. Specify predominant features: * With Delirium: if delirium is superimposed on the dementia * With Delusions: if delusions are the predominant feature * With Depressed Mood: if depressed mood (including presentations that meet full symptom criteria for a Major Depressive Episode) is the predominant feature. A separate diagnosis of Mood Disorder Due to a General Medical Condition is not given. * Uncomplicated: if none of the above predominates in the current clinical presentation Specify if: * With Behavioral Disturbance Note: Also record cerebrovascular condition. Subtypes The following subtypes must be used to indicate the predominant feature of the current clinical presentation: With Delirium This subtype is used if delirium is superimposed on the dementia. With Delusions This subtype is used if delusions are the predominant feature. With Depressed Mood This subtype is used is depressed mood (including presentations that meet symptom criteria for a Major Depressive Episode) is the predominant feature. A separate diagnosis of Mood Disorder Due to a General Medical Condition is not given. Uncomplicated This subtype is used if none of the above predominates in the current clinical presentation. Specifiers With Behavioral Disturbance The specifier With Behavioral Disturbance can also be used to indicate clinically significant behavioral disturbances (e.g., wandering). Recording Procedures The specifier With Behavioral Disturbance can be applied to each of the subtypes (e.g., Vascular Dementia, With Depressed Mood, With Behavioral Disturbance). In addition, the cerebrovascular condition (e.g., stroke) should be recorded. DSM-5 For more information, see Major and Mild Neurocognitive Disorders Diagnostic Criteria A'''. The criteria are met for major or mild neurocognitive disorder. '''B. The clinical features are consistent with a vascular etiology, as suggested by either of the following: # Onset of the cognitive deficits is temporarily related to one or more cerebrovascular events. # Evidence for decline is prominent in complex attention (including processing speed) and fronto-executive function. C'''. There is evidence of the presence of cerebrovascular disease from history, physical examination, and/or neuroimaging considered sufficient to account for the neurocognitive deficits. '''D. The symptoms are not better explained by another brain disease or systemic disorder. Probably vascular neurocognitive disorder is diagnosed if one of the following is present; otherwise possible vascular neurocognitive disorder should be diagnosed: # Clinical criteria are supported by neuroimaging evidence of significant parenchymal injury attributed to cerebrovascular disease (neuroimaging-supported). # The neurocognitive syndrome is temporally related to one of more documented cerebrovascular events. # Both clinical and genetic (e.g., cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy) evidence of cerebrovascular disease is present. Possible vascular neurocognitive disorder is diagnosed if the clinical criteria are met but neuroimaging is not available and the temporal relationship of the neurocognitive syndrome with one or more cerebrovascular events is not established. Differential Diagnosis Other neurocognitive disorders Since incidental brain infarctions and white matter lesions are common in older individuals, it is important to consider other possible etiologies when an NCD is present. A history of memory deficit early in the course, and progressive worsening of memory, language, executive function, and perceptual-motor abilities in the absence of corresponding focial lesions on brain imaging, are suggestive of Alzheimer's disease as the primary diagnosis. Potential biomarkers currently being validated for Alzheimer's disease, such as cerebrospinal fluid levels of beta-amyloid and phosphorylated tau, and amyloid imaging, may prove to be helpful in the differential diagnosis. NCD with Lewy bodies is distinguished from major or mild vascular NCD by its core features of fluctuating cognition, visual hallucinations, and spontaneous parkinsonism. While deficits in executive function and language occur in major or mild vascular NCD, the insidious onset and gradual progression of behavioral features or language impairment are characteristic of frontotemporal NCD and are not typical of vascular etiology. Other medical conditions A diagnosis of major or mild vascular NCD is not made if other diseases (e.g., brain tumor, multiple sclerosis, encephalitis, toxic or metabolic disorders) are present and are of sufficient severity to account or the cognitive impairment. Other mental disorders A diagnosis of major or mild vascular NCD is inappropriate if the symptoms can be entirely attributed to delirium, although delirium may sometimes be superimposed on a preexisting major or mild vascular NCD, in which case both diagnoses can be made. If the criteria for major depressive disorder are met and the cognitive impairment is temporally related to the likely onset of the depression, major or mild vascular NCD should not be diagnosed. However, if the NCD preceded the development of the depression, or the severity of the cognitive impairment is out of proportion to the severity of the depression, both should be diagnosed.